From a patient’s perspective, there are very few characteristics of a dental professional that really matter: Is the dentist kind? Is the dentist patient? Does the dental work last? Is the shot painful?

Administering local anesthesia—giving the shot—can often be one of the most nerve-wracking elements of being a dentist, especially when patients often have no other way to judge the quality of dental work they have received. All they can really surmise about the quality of their clinician is whether getting a shot hurts or doesn’t hurt. Despite our efforts as dental professionals to follow all the rules of local anesthesia, the results are sadly inconsistent. Some patients may find that the technique in delivering local anesthesia is fabulous and they don’t feel a thing, while others may find the exact same technique very painful.

Along with clinical expertise, there are a variety of factors that may affect the patient’s perception: (1) injection into a muscle attachment, (2) speed of injection, (3) patient’s pain tolerance, and (4) patient’s preconceived notions

Innovation in the field of local anesthesia has been slow, inconsistent, and not well adopted. Our needles, syringes, and types of anesthetic solutions today are not much different from those same things from decades ago. Often, we find ourselves telling our patients that we wish there were a better way to administer anesthesia without all the pain, fear, unpredictability, and discomfort associated with it and are stymied when patients inquire about our ability to “do it better than their previous dentist.”

Directa, an industry leader in the innovation of local anesthesia techniques, has developed Calaject, a computer-assisted local anesthesia delivery system for everyday use. The system controls the flow rate of anesthesia delivery, thereby ensuring that the patient receives a standardized quality of injection at every appointment. The computer settings are customized based on the location of the injection so the speed of anesthetic expression is modulated to ensure minimal tissue distention and its resulting sting.

Overall expression of anesthetic, along with requisite aspiration to avoid arterial infiltration, is conveniently controlled with a foot pedal. The machine has a convenient pen grip so that the needle can be kept still. Not only does this benefit the patient but it also allows the operator to stand in an ergonomically correct position (

During the evaluation period, I had several unique opportunities to try the Calaject on patients who otherwise would have dreaded the local anesthesia process. One instance stands out in my mind. I needed to perform several anterior maxillary restorations, necessitating local anesthesia directly under the nose. This is a procedure that I generally hate performing as it is difficult to do without causing discomfort, even when I attempt to employ the gentlest practice. I had to give several injections in that area. My first notable experience was the pen grip, which I found simply more ergonomically friendly for my hands. The most significant and memorable experience, however, was the surprising lack of response from this otherwise extremely jittery and anxious individual. The controlled slow flow from the delivery unit allowed for this, and both the patient and I were quite grateful.

The Calaject was given to the Catapult Education product review board, a group of dentists with a variety of backgrounds and clinical environments. They were asked to rate their experience with this highly innovative, computer-aided product with regard to the following criteria:

Ergonomic stress with Calaject compared to manual injection

Type of injection Calaject is best suited for

A majority of the respondents to the survey were very satisfied with Calaject and saw the addition of a computer-assisted local anesthesia delivery as a benefit to their practice. Respondents found it had a very favorable design with an ergonomic handpiece, an auditory signal and a visual display for the flow rate, and a self-aspirating feature with the foot pedal. Overall, the respondents found the machine and its components to be cost-effective. It was noted that because of the slower flow rate, operators were able to start procedures immediately after administration. Most importantly, the patient did not report any pain during the injection.

“Calaject offers precise control over anesthetic dosing, effectively reducing patient discomfort and minimizing injection errors. Additionally, the beeping feature of Calaject gives patients a perception that dentistry is akin to medicine, which may encourage them to take their oral health more seriously.”

“It’s essential to understand the correlation between flow rate and patient discomfort. The slower flow rate is designed to minimize discomfort, which can significantly enhance the patient experience.”

“Given the benefits and advanced technology of Calaject, I advocate for its immediate incorporation into dental and dental hygiene educational programs. Introducing this tool early in a student’s training can familiarize them with its use and benefits, including precise control over anesthetic dosing, reduced patient discomfort, and minimized injection errors. Furthermore, early exposure to such advanced technologies could foster a mindset that prioritizes patient comfort and the overall patient experience, which is crucial in modern dental practice.”

“It is a very nice looking unit. Patients said they felt no discomfort at all.”

There were a few negative responses, summarized below:

Respondents reported disadvantages when the patient moves, for instance, in a pediatric office, and that the flow rate can be too slow for pediatric patients.

Despite these unfavorable characteristics, the resounding majority of responses were highly positive, with almost every respondent mentioning that they would recommend this product to a colleague. For these reasons, the Catapult Education product review board proudly awarded Calaject with the Catapult Vote of Confidence™.

Articles

Ronvig’s Calaject, brought to you by Directa USA: Catapult’s Vote of Confidence is awarded for everyday use in computer-assisted local anesthesia delivery. 

Innovative Technology Takes the Guesswork Out of Injections

For this column, I wanted to share the history and science of orthodontic retention, so I knew I needed to contact Brian Gray, DDS, for my conversation. He is a fellow in 3 academies and a master in the Academy of General Dentistry (AGD). At AGD, he was awarded the Lifelong Leadership and Service Recognition Award—fewer than 1% of dentists have received this award since its inception. Dr Gray is chief dental officer at Candid, and when he took on this role, one of his goals was to evolve a next generation of retainers. Candid is a dental company that provides CandidPro clear aligner solutions. Our discussion on the science of retention leads to understanding why the right materials and protocols are needed for lasting orthodontic results.

Why did you start looking at a next-generation retention solution as an important part of the whole orthodontic process?

In the past, when patients finished orthodontic treatment, they got their retainer and returned to their general practitioner [GP] for their regular dental checkups. If the patient didn’t adhere and noticed that a tooth was starting to relapse, the GP would usually send them back to the orthodontist. That extra appointment was just another hassle in their day, so often they would let it slide, and the teeth would shift even more. Retention must be for life. But it must be based in science to produce lasting results. GPs now represent such a significant part of aligner treatment that understanding retention has become an integral part of long-term patient care.

 We want a retainer to act as a gentle reminder for the teeth to stay in the final position after treatment. The true standard of care for removable retention has been the Hawley retainer—it has a long life span unless it gets lost or the dog eats it—and it can be adjusted in the case of simple relapse. A Hawley maintains tooth position because the scalloping of the acrylic on the lingual surface locks teeth in place. But the problem is, when you wear that type of retainer, it is like going back to high school. After patients have had their teeth straightened with a clear aligner system, they don’t like to wear a Hawley because it looks and feels strange.

LS: So, from a scientific point of view, what makes a good retainer?

 An ideal retention appliance has 2 important components: It needs to fit very well and maintain its shape. In other words, a clear plastic retainer needs to be precise and know where to stay. In the past, some doctors would use the final aligner as a retainer. The plastic would fatigue very easily, and then the teeth would start to shift a bit in the retainer. If the plastic is not holding the teeth in position, they tend to move in a transverse direction, sideways. But the proper retainer material changes the game.

Studies showed that certain first-generation aligner and retainer plastics would start to fatigue in as little as 1 week after being worn for 8-hour days. Based on that information, Candid started searching for a new, more reliable material. We saw improvement but still observed too much fatigue with second-generation materials. For efficient retention, patients had to update their aligners about every 6 months. So we continued analyzing the data to deliver the best retention plastic available. And we nailed it. We chose the latest clear, stain-resistant Zendura FLX material because of how well it resists cracking and deformation.

Candid performed rigorous stress analysis tests on plastic materials to see which one was going to have the best memory and last the longest. We ran fatigue tests for strength, memory, and rigidity. We then ran a double-blinded clinical trial to verify the best trim and thickness that patients found to be most comfortable.

LS: Why not use an aligner as a retainer?

There is a big difference between clear aligners and retainers. Clear aligners are designed to move teeth. Retainers are designed to keep teeth from moving—to maintain a specific position. The fit needs to be highly intimate with the teeth, so they have less of an opportunity to start movement under the plastic. A poorly made retainer will allow the teeth to drift or shift, but a well-made retainer will hug the teeth and hold them in place.

Also keep in mind that a retainer will wear out more quickly if the patient is a heavy grinder or bruxer. This causes the plastic to flex and not hold on to the sides of the teeth as well.

It is important to know that a precise-fitting retainer relies on 2 components of accuracy for success. First is the veracity of the impression or scan. Second is the validity of the model used to thermoform the clear retainer. The scan, which gives us data on tooth position, is turned into a solid lithograph model. When the models are fabricated, they must be made with a highly accurate printer. We found that Carbon printers were the best in this regard. Super-precise models allow our thermoforming units to deliver the fidelity we were looking for when we started this mission.

The most important part is the type of plastic used to form over the model. The material needs to be able to [reach] into the interproximal spaces to help hold the teeth. Without that, the teeth will be allowed to shift. When Candid came up with the design of our next-generation retainer, we looked for these key things: the proper material, being able to obtain the best data from the scan, and the highest accuracy of printing.

The next generation of retainers Candid just launched does not rest on the gingiva, and this is very important. It is designed to be supragingival, so it does not impinge at all on the soft tissue. But because it is extended lower, the retainer can now leverage physics to grab on to more teeth and lock into the interproximals between the teeth to keep them from moving. And this helps to prevent that transverse movement.

 Teeth actually relapse by wanting to return to their previous position. This has a lot to do with the periodontal ligament. Without getting too deep, there are 3 leading theories on strain-based bone remodeling in orthodontic movement. They all pretty much correlate on relapse rotation, which may occur because round circular fibers act like a rubber band. [Before orthodontic treatment], the tooth is out of position, but the circular fibers are passive. Now we move the tooth, and even though it is in an ideal position, those circular fibers are stretched and want to return to their original passive pre-rotated position. The longer the aligned tooth is held in its ideal position, the fibers start to relax and become passive in their new position. This change occurs over a lengthy period, which is why adherence and the best retentive device are so critical. It is also why Candid spent so much research and development time to create a retainer to allow the dentition to remain ideally positioned.

 The exciting part of working at Candid is their state-of-the-art [research and development team]. The company is quick, agile, and has a ton of game-changing innovations in progress. The next 18 months will see much disruption and change in our incredible profession. Candid already has a retainer update coming in July, adding some extra features. You do have to be a CandidPro provider to purchase retainers through the CandidPro website.But patients don’t have to have gone through CandidPro aligner treatment to get PermaForm retainers.

The research and science that went into the creation of this next generation of retainers from CandidPro provide significant upgrades in fit, comfort, and longevity. Patients spend much time and money on straightening their teeth, and Dr Gray and Candid are determined to keep those teeth in place.

The launch of Candid’s next-generation retainer is backed by its research of the best materials and protocols.

The Science Behind Orthodontic Retention

In recent years, 3D printing has emerged as a groundbreaking technology with applications across various industries. In dentistry, 3D printing has revolutionized the way dental professionals approach treatment planning, prosthetics, and even education. The precision, efficiency, and customization capabilities of 3D printing have transformed the field, offering numerous benefits for practitioners and patients alike. Many of the practices I work with have started to incorporate 3D printing into their daily routines, so I wanted to explore some of the current use-case scenarios.

One key use of 3D printing in dentistry is in the fabrication of dental models. Traditionally, dental models are created using impression material and plaster models, which are time-consuming and often result in inaccuracies. With 3D printing, dental professionals can create highly accurate, detailed models in a fraction of the time. These models are invaluable for treatment planning, allowing dentists to visualize the patient’s dental anatomy in 3 dimensions and plan procedures with greater precision.

Another significant application of 3D printing in dentistry is in the fabrication of dental prosthetics, such as crowns, implant restorations, bridges, and dentures. The technology allows for the creation of custom prosthetics that are perfectly tailored to the patient’s individual anatomy. This not only improves the fit and comfort of the prosthetic but also reduces the need for adjustments, saving time and money for patients and practitioners.

Surgical guides for dental implant procedures are also benefiting from 3D printing. These guides are designed based on the patient’s cone beam CT scans and are used to precisely position the implants during surgery. This not only improves the accuracy of the procedure but also reduces the risk of complications and ensures better long-term outcomes for the patient.

Furthermore, 3D printing is transforming the field of orthodontics. Traditionally, orthodontic appliances such as braces and aligners were fabricated using manual methods, which were often time-consuming and prone to errors. With 3D printing, orthodontic appliances can be custom-made for each patient, resulting in more comfortable and effective treatment.

Beyond clinical applications, 3D printing is being used in dental education. Dental schools and training programs are using 3D printing to create anatomical models for teaching purposes, allowing students to practice procedures on lifelike models before working on actual patients; these are far more accurate than the Dentiforms of old. This hands-on training not only enhances the learning experience but also improves the skills and confidence of future dental professionals.

In conclusion, 3D printing is revolutionizing the field of dentistry, offering numerous benefits for both practitioners and patients. From improved treatment planning and prosthetic fabrication to enhanced surgical precision and educational opportunities, the uses of 3D printing in dentistry are vast and far-reaching. As the technology continues to evolve, it is likely to play an even greater role in shaping the future of dental care. Combined with the rise of artificial intelligence, which I discussed in a previous article, it’s an exciting time to be a dentist.

Dentists can leverage the ever-evolving and advancing technology to provide better care for their patients and expand practice offerings. 

The Transformative Potential of 3D Printing

The mouth is complex, subject to variations in bone density, jaw structure, and overall health. These often complicated variations may present challenges when it comes to patients looking for safe, sturdy, and trusted implant options. For instance, some patients may have robust jawbones with sufficient bone density, making them suitable candidates for traditional dental implants. These implants are surgically placed directly into the jawbone and provide a sturdy foundation for tooth replacement.

One must consider that not all patients possess adequate bone volume or density to support traditional implants. In such cases, alternative options like short or mini dental implants or procedures such as bone grafting may be necessary to augment the bone structure before implant placement. Part of a clinician’s role when considering dental implants for a certain case is looking at the big picture, according to Indraneel Kanaglekar, senior vice president and global dental president of dental implant manufacturer ZimVie.

“When you’re selecting an implant or when selecting an implant company, clinicians look at the technology, they look at the failure rates, the depth of the portfolio, the science behind the implant technology, as well as increasingly the digital workflow technologies and the restorative options available,” Kanaglekar says. “But for a particular case, the most important thing would be the shape and size of the implant.”

With the influx of new dental technologies and materials, clinicians are presented with myriad options when it comes to choosing which implant works best. Consider dental implants as a branching path, stemming from 2 main types—endosteal implants and subperiosteal implants. Per the American Academy of Implant Dentistry (AAID), endosteal implants are placed directly in the jawbone and are typically the standard and popular implant choice.

 These implants are usually crafted from titanium in a screw shape.

“Most of our implants are placed at or just below the bone level. And those are called bone-level implants,” Kanaglekar says. “There are some dentists who still prefer to use a tissue-level implant, which means the implant protrudes out of the bone and it sits in the tissue.”

Subperiosteal implants are placed differently, under the gum and on or above the jawbone. These implants are less standard, according to the AAID, but are often appropriate for cases where the patient lacks a healthy natural jawbone and is unable to undergo bone augmentation.¹ Subperiosteal implants involve a metal framework that rests on the jawbone, with posts protruding through the gums to support the artificial teeth. This alternative approach allows for greater flexibility in accommodating patients with compromised bone density or those who may not be suitable candidates for traditional endosteal implants.

The choice between endosteal and subperiosteal implants is influenced by various factors, including the patient’s oral health, bone structure, and personal preferences. Advances in dental technology and materials have further expanded the array of implant options within these 2 main categories. For example, the development of zirconia implants provides an alternative to traditional titanium implants. Zirconia implants may offer esthetic benefits, as they are tooth colored and can blend seamlessly with natural teeth, making them particularly appealing for patients concerned about the visual aspect of dental restorations. It is important to note, however, that zirconia implants are still relatively new to the US market, and questions regarding their efficacy and longevity may be important to consider. One study from 

 claims that a mixed titanium-zirconia implant did better in terms of survival rates, marginal bone loss, and bleeding on probing than either zirconia or titanium alone.

When a patient’s jawbone is insufficient or unable to support traditional dental implants, alternative implant types and techniques become essential to restore the structural integrity of the jaw and create a suitable foundation for implant placement. These alternatives focus on stimulating bone growth in the affected areas, effectively preparing the jaw for successful implant integration.

One such technique is bone grafting, a common procedure used in augmenting bone volume. In cases where the patient has experienced bone loss due to factors like trauma, periodontal disease, or atrophy, bone grafts involve transplanting bone tissue from another part of the body, a donor source, or synthetic materials to the deficient area. This procedure promotes the formation of new bone, strengthening and thickening the jawbone to a level that can support dental implants securely. Bone grafting is a versatile solution that caters to various degrees of bone deficiency, allowing clinicians to tailor the treatment to the specific needs of each patient.

 Bone grafting can be supplemented by the use of materials like a bone graft plug, for example the OsteoGen® by Impladent.

The use of guided bone regeneration (GBR) and sinus lifts are techniques designed to enhance bone volume and quality in specific areas of the jaw. GBR involves placing a barrier membrane over the deficient bone area, preventing soft tissue invasion and promoting the growth of new bone. Sinus lifts, on the other hand, are particularly useful for the posterior upper jaw where the bone void created by thenatural sinus cavity may impede implant placement. During a sinus lift, the sinus membrane is lifted and bone graft material is inserted into the space below, encouraging bone growth and creating a more stable foundation for implants.

Other dental implant procedures leverage new technologies for implant placement. Examples include immediately loading implants, mini dental implants, and the All-On-X series of implants.

Immediate load implants: These implants are as described, crafted with the ability to have a temporary tooth placed on the same day as the dental implant placement. These implants may provide a convenient option for patients who have the structure in place to safely take advantage of this same-day treatment. Systems such as Straumann® TLX Implant System suit both conventional and immediate loading, for optimized chairside efficiency.

Mini dental implants: These smaller implants are designed to provide a less-invasive implant experience for patients. Per the AAID, they are typically used to stabilize a lower denture.¹ MOR®mini implants from Sterngold are designed for simplicity and affordability, all while being designed for immediate loading.

All-On-X implants: Procedures using these implants leverage 4 to 6 positions in the mouth to strategically support a full arch of teeth. This type of implant technique and treatment may reduce treatment time, as it eliminates the cost, time, and added surgery of placing multiple different implants, in favor of placing a few strategic ones.

According to Kanaglekar, the design of dental implants has undergone significant evolution in recent decades, reflecting advancements in materials, technology, and a deeper understanding of biomechanics. One notable aspect of this evolution is the transition from predominantly straight implants to the adoption of tapered designs, each with distinct implications for how they integrate into the oral environment.

“Previously, around 20 to 30 years back, when the implant technology started developing, most of the implants were largely straight, or even if they were tapered, they were tapered at the apical point or at the bottom,” he says. “Over time, the technology has evolved and most of the implants are fully tapered.”

The tapered design enhances primary stability during implant placement, especially in cases where the available bone may be compromised or limited. By gradually widening toward the coronal end, tapered implants engage more surface area within the bone, maximizing initial fixation and reducing the likelihood of micromovements that could hinder osseointegration. This improved stability is particularly beneficial in situations where immediate or early loading of the implant is desired. Mimicking the anatomy of a tooth root, tapered implants distribute occlusal forces more evenly along the surrounding bone. This helps minimize stress concentrations, reducing the risk of complications such as bone resorption or implant failure over time. The biomechanical advantages of tapered implants have led to their widespread acceptance and utilization in various clinical scenarios.4 ZimVie’s T3® PRO Tapered Implants and the TSX™ Implants take advantage of the tapered design to provide enhanced clinical results including more stability and defense against peri-implantitis.

Another factor that impacts implant design is the connection, according to Kanaglekar. “The connection, meaning the screw of the abutment that goes into the implant, what type of connection is that? Now, a simple analogy would be as if it were a Phillips screw or hex screw vs an octagonal screw. It’s similar to that. And there are various types of connections,” he says. “Our implants come with primarily 2 different connections. One is what we call internal hex, and the other connection is named Certain®. We believe both these connections provide an excellent seal, where the bacteria do not enter the implant after placement, while also helping form tissue around the implant and encouraging bone growth around the implant.”

Connections play a vital role in dental implant design as they are critical components that link the implant to the prosthetic structure, such as crowns, bridges, or dentures. The connection between the implant and the prosthetic component is crucial for the overall success, stability, and longevity of the implant-supported restoration.

More Than Skin Deep: Surface Treatments in Dental Implant Design

Surface treatments are crucial in implant design because they significantly impact osseointegration, which is the direct structural and functional connection between the implant and the surrounding bone. The surface characteristics of dental implants play a pivotal role in determining the success, stability, and long-term performance of the implant.

“The surface technology that is used to provide roughness to the implant is another place where implants differ from each other,” Kanaglekar says. “At a very high level, there are 2 types of surface technology that you can use to make the implant surface. One is additive surface treatment, where you add some sort of rough coating on the surface. The other is subtractive, where you etch the implant, or you blast the implant and take something out of that surface and make it rougher. Over time, we have come to believe that the subtractive surface roughness technology worked really well for us.”

For ZimVie, 20 years of data have supported its Osseotite® dental implant and its increased contact osteogenesis. It has a unique 1- to 3-µm peak-to-peak surface that leverages an acid-etch process, and per ZimVie’s website, its surface features are specifically designed and sized to entangle fibrin strands of the blood clot.⁶ “What we have tried to do is create an implant that is rougher to the collar–which is the top portion of the implant–and then we still create a small amount of softness on the collar, where it encourages bone growth, but does not become so rough that it attracts bacteria.” Kanaglekar says.

Alternatively, additive treatments use mechanical or chemical processes to add material that changes the surface of the dental implant. There are a variety of methods to adding materials to the surface, including through a superficial addition and through a deeper integration. Integration implies that the material is going directly into the implant’s substrate material, for example, introducing ions of fluoride, whereas a superficial addition typically comes in the form of coating the surface. According to a study done in BioMed Research International, coating techniques can include titanium plasma spraying, plasma sprayed hydroxyapatite coating, alumina coating, and biomimetic calcium phosphate coating.

Although both subtractive and additive are valid techniques in surface treatments, dentistry has shifted to focus on more subtractive measure, Kanaglekar says. “We believe we have some of the best surface technologies on the market. And the reason why the industry typically believes that subtractive surface technologies are better than additive is because there is a belief that sometimes these additive technologies, the particles can later on aggregate or create issues for infection,” he says. “That said, we still have some legacy lines that utilize hydroxyapatite surface coatings. And again, in that sense as well, our surface technology, what we call MP-1® HA is very different. Backed by clinical data, we believe that if you want to go for additive technologies, we believe we have the best available.”

The choice between a superficial addition or deeper integration of materials depends on specific clinical considerations, including the desired outcome, the materials used, and the targeted improvement in implant performance. Each method has its advantages and potential drawbacks, and the decision may be influenced by factors such as the patient’s oral health, bone quality, and the overall treatment plan.

Choosing the right dental implant is a critical decision for clinicians and their patients, and several factors can come into play.

“The most important thing would be the shape and size of the implant. Because if it’s a narrow ridge, then you would need a smaller implant. If it’s a thick bone and in the posterior then you would need a bigger implant,” Kanaglekar says. “The size of the implant would also be dependent on the patient anatomy and the level of bone they have.”

Clinicians may want to consider various factors in terms of the implants that they offer. “For the long term, dentists would typically want to look at the history of a particular implant’s failure rate, or long-term survival rates, as well as the science and publications available about the surface technology and about the bone loss or bone preservation around that after the implant is placed, as well as the restorative options that can provide optimum esthetic and functional benefits,” Kanaglekar says.

For instance, mini dental implants may be optimal for patients with less jawbone density who still desire a less invasive procedure. This might be ideal for patients with smaller mouths or any other patient whose jaw mass cannot support traditional dental implants.

“You will come to a natural conclusion whether, in this case, it’s better to have individual implants or an implant-supported bridge. Typically implant-supported bridge or a full arch treatment would be recommended,” Kanaglekar says. “If you have multiple adjacent teeth that are missing, or your patient is partially edentulous or fully edentulous—if there are, let’s say, 2 teeth missing but there are multiple teeth in between that are healthy and the smile is good, then the dentist is going to recommend 2 different implants even though there are 2 missing teeth. But if it’s adjacent teeth or more than 3 or 4 teeth missing and it’s a partially edentulous case, then you are most likely going to go for an implant-supported bridge or a full implant-supported denture.”

Steps to determining which implant best suits which case may lie in the dental practice’s ability to harness the right technology and tools.

Technology Workflows Bolster Implant Care

Digital workflows can be key in determining the right type of implant for your patient. From smile visualization programs to software like RealGUIDE™ from ZimVie, there are more options now to find the right fit for the dental practice.

RealGUIDE is a cloud-based software suite that enables implant planning, design, surgical guide design, and other programs. By combining these functionalities in a single platform, RealGUIDE aims to enhance efficiency, accuracy, and collaboration, according to Kanaglekar.

“These days, the best way to assess a case would be to do a comprehensive surgical and restorative planning, which will give you a good idea on not just the shape and size of implant but how and at what angle it should be placed,” he says. “You start with taking a 3Dx-ray or a CBCT scan. We’ll also merge that with an intraoral scan, which gives you a view of the other teeth and the tissue.”

Once those are imported in the software, clinicians can best determine and design which implant will work for the case, assessing the location of nerves, assessing bone density, and moving onward to create a surgical guide for the case. The surgical guide can then be sent to ZimVie, where it can be manufactured or, if the clinician owns a 3D printer, they can print it chairside. Other platforms, such as the Romexis® 3D Implantology from Planmeca, provide platforms that enable both digital implant design and surgical guide design. Planmeca also provides a full implant library, which allows clinicians to keep a database of both implant and surgical guide designs, downloadable from Planmeca’s website.

“Going forward, we’ll continue to innovate on implant design,” Kanaglekar says. “We want to improve our implant offerings in terms of shapes, sizes, technology, but also make sure that these improvements are tied to this end-to-end digital workflow that will improve practice efficiency and restorative comfort.”

Types of implants and techniques. American Academy of Implant Dentistry. Accessed March 11, 2024. https://aaid-implant.org/what-are-dental-implants/types-of-implants-and-techniques/

Fernandes PRE, Otero AIP, Fernandes JCH, Nassani LM, Castilho RM, de Oliveira Fernandes GV. Clinical performance comparing titanium and titanium-zirconium or zirconia dental implants: a systematic review of randomized controlled trials. 

Weinlaender M. Bone growth around dental implants. 

Nandini N, Kunusoth R, Alwala AM, Prakash R, Sampreethi S, Katkuri S. Cylindrical implant versus tapered implant: a comparative study. 

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Inchingolo AM, Malcangi G, Ferrante L, et al. Surface coatings of dental implants: a review. 

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The Osseotite dental implant. ZimVie. Accessed March 12, 2024. https://www.zimvie.com/en/dental/dental-implant-systems/3i-osseotite-implant.html

Jemat A, Ghazali MJ, Razali M, Otsuka Y. Surface modifications and their effects on titanium dental implants. 

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Flanagan D. Rationale for mini dental implant treatment. 

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With a variety of designs and types, it is vital to determine which implant works best for which case. 

Understanding Dental Implant Design

Oh, the things I’ve gotten to do in my life!Some have been a result of dumb luck, being in the right place at the right time—like catching that foul ball at a Royals game about 10 years ago. Yet some of the best things that have happened in my life were simply being faced with an opportunity and thinking: “What the heck? Take some chances.”

In the fall of 2017, long before we even thought a pandemic could happen, I was browsing my Twitter (now called X) feed and being a geek, I follow a lot of National Aeronautics and Space Administration (NASA) feeds. On that fateful day I saw a post stating that they were looking for people with a love of NASA and a social media following/presence. The offer was to apply for a special program that would allow those lucky enough to be chosen to come to Kennedy Space Center in Florida and witness a rocket launch while continually posting to their social media channels about the experience.

Now, I’m no social media guru. I don’t have tons of followers. However, I immediately thought: “What the heck? The worst that can happen is that they say no and I get to tell people NASA turned me down.” I mean, in my geeky mind, even a rejection from NASA was something to crow about.

Six months later, on April 2, 2018, I was getting a full-blown tour of the Kennedy Space Center and all the tech glory it contained. Then I stood in the press section and watched SpaceX launch a Falcon rocket to the International Space Station. I was as close to that launch as NASA deemed safe, and let me tell you, the shock wave that came off that thing hit me in the chest like a full-volume Led Zeppelin concert. It was magnificent and awe inspiring.

So what does this have to do with dentistry? Simply put, many of us in the profession are sticklers.We find something that works and we tend to stick with it—sometimes way longer than we should.In the days before digital impressions, I used to tell salespeople the hardest thing to do was to get a doctor to change their impression material—and that was so true.

However, change is good. Bluntly put, change works. Dentistry is a high-burnout profession. Not many people hang it up early, but a lot of us struggle mightily in clinical practice. Like baseball, we go through slumps and streaks. Sometimes you get a phase where it seems you can do no wrong.Patients get numb in seconds, crowns fit like they were sent straight from heaven to your office, and that class IV composite on No. 9 looks like the tooth never fractured. Other times you send folks home because anesthesia didn’t take, endo files fracture, and your “simple” crown fits like the proverbial “socks on a rooster.” The good news is that tough times don’t last but tough people do.

So this month let’s consider some things that, from a restorative standpoint, will make your life easier and your clinical results exactly what you expect of yourself.

So much of what we do today depends on chemistry, and yet not many of us have degrees in the field. That can make bonded procedures stressful and sometimes confusing.Lots of bottles, lots of syringes, and lots of confusion are frequently the norm for us.What works with what?If I bond a post with this material, will it stay or is the patient going to come back in 3 months with a crown in their hand that contains all the buildup and the post?

I love chemistry, but I am by far not an expert in the subject and that is why I love to keep it simple.One of my favorite bonding agents is Futurabond U from VOCO. There are 2 genius parts of this product. The first is that it works with everything. When the smart people at VOCO say “universal,” they mean universal. The material is both light cure and dual cure. That means even in bonded posts, the material will set in areas that the curing light will never reach adequately. Plus, it works with every bonded material out there. Futurabond U is material agnostic, which means that composites, buildup materials, and bonded cements work equally well with impressive bond strengths.

The second impressive thing about Futurabond U is the packaging/dispensing system. It comes in a blister pack that holds the 2 components of the system in separate wells. Simply push on the bubble in the package and those 2 components flow together. You then break the foil on the package and stir the contents. The genius of this is that every mix is a fresh mix. You never have to worry about solvent evaporation or the material losing potency sitting in a bottle or syringe.

Another terrific bonding agent is from Vista Apex and is called RE-GEN Universal Adhesive, which works with every material. The product is the first universal bonding agent that employs bioglass as an active ingredient. In keeping with the idea of simplicity and predictability, bioglass has more than 50 years of medical use. It was originally developed for use in orthopedic surgeries to stimulate bone growth in difficult cases. What is amazing about bioglass in our profession is that it forms a hydroxyapatite-like surface where it touches tooth structure, which means it promotes the regeneration of healthy tooth structure (hence the name RE-GEN).

Bioglass also has the amazing property of broad antimicrobial effects, which means that it helps promote healing and prevention of recurrent caries at the margin of restorations. Considering how recurrent caries is the main problem in adhesive dentistry, being able to kill bacteria at the marginal interface is a huge plus. Studies show that the average life span of a multiple surface composite restoration is around 5 years. I feel we can do better than that and I firmly believe RE-GEN products can help with that.

One line that I feel the profession needs to know more about is the Giomer-containing products by Shofu. Giomer is a proprietary filler particle that Shofu created and engineered. The products that contain Giomer release and recharge 6 ions: fluoride, strontium, sodium, aluminum, silicate, and borate. When these ions are combined, they inhibit plaque while neutralizing the acids that plaque-containing microbes create.

It’s a bit amazing to me that Giomer was created well over 20 years ago and yet many practitioners are not aware of it. As I noted above, the average life span of a multisurface composite is around 5 years. The margin is where the battle of restorative longevity is won and lost. Sending in as many reinforcements as we can to the margin can truly help make a big difference in our clinical outcomes.

I’d like to also add that Shofu has done a tremendous job in keeping prices low for its outstanding materials. As a business owner, the doctor is always performing a high-wire act to ensure profitability and Shofu is helping us in that area. As I’ve said many times in the past here, you can have the best hands in the profession, but if you cannot stay in business, you won’t be able to help many of those in desperate need of our care.

The goal of all restorative dentistry is to return the tooth being treated and the patient back to a state of health that can be maintained. In striving to achieve that sometimes difficult goal, it is important not only to place the correct material but also to place it well. Contours and contact matter to the longevity of a restoration. The restoration must return the tooth to as close to ideal as clinically possible while also allowing the patient to be able to perform their home care routine.

Composites can be difficult to place properly. The problem stems from several factors, but perhaps the most common one is that many of the matrix systems we use were designed to be used with amalgam. Composite is a completely different material from amalgam and it is important that we use a matrix system that is designed for use with it.Garrison Dental Solutions recently released a “leap forward” sectional matrix system called the Strata-G and it definitely bears a close look.

The Strata-G kit is a complete system for placing composites with amazing results. It contains rings, assorted bands (for both posterior and anterior), assorted Strata-G wedges, ring placement forceps, and mini polishers.

The system is designed to make it as easy as possible to create multisurface composites that have proper contacts and proper contours. The bands are manufactured to re-create the contour of the tooth while the rings, made of nitinol (ni-ti), open easily yet contract with a significant force. These rings allow for easy placement yet due to the ni-ti they hold the bands exceptionally well. This incredible material also creates pressure that slightly separates the adjacent teeth. When the ring is removed, the periodontal ligament rebounds, returning the teeth to their original position and in the process creating a snug and ideal contact. Basically, the form of the band creates ideal contours while the ring allows for ideal contacts.

The wedges are also key. The underside is a V shape and is formed out of a flexible polymer. The V and the polymer allow the band to have flexibility. This allows the wedge to slide easily against the band, and the wedge can bend inward at the greatest curvature of the gingival box while also expanding as it enters and exits the area. The result is a gingival margin that is sealed with minimal chance of an overhang because the wedge allows the band to perfectly contour to the gingival margin.

What I’ve hoped to accomplish here is to encourage you to try some new things that have worked well for me. Dentistry is a constantly changing landscape, and there are lots of things coming to market that can really impact our abilities, our stress levels, and our clinical outcomes. If you are looking for better ways to help make your treatment better, I encourage you to step just a bit outside your comfort zone and give some new things and new ways a try. Progress continues unabated and we need to change simply to stay current. See you next month!

Sometimes improving your dental practice is all about stepping outside your comfort zone. Here are a few techniques and products that may enable that.

Taking Chances and How Those Chances Shape Our Future

Whether looking at an individual clinic or taking a macro-perspective that includes dental product manufacturers, providing dental care is a resource-heavy undertaking. But that might not always be the case.

Although some resources are required and some waste will be generated by both dental clinics and the companies making the products those clinics use, a new focus on sustainability throughout the dental industry is helping make it possible to provide top-tier oral health care while operating as efficiently as possible and significantly reducing waste.

When it comes to the practice level, there are numerous ways to reduce water and energy use. Replacing single-use plastics with compostable or biodegradable alternatives can also reduce a practice’s environmental footprint. Another approach to reducing dental waste is to prevent dental disease in the first place. This is one of the concepts underpinning the Sustainability in Dentistry program founded by the FDI World Dental Federation and Dentsply Sirona. The program includes online courses, sustainability resources, and an annual global sustainability award. With an approach focused on evidence-based oral care and prevention combined with guidance on steps to improve sustainability within a dental practice, this global effort aims to empower dental professionals to make a change that affects their practice. More details on the Sustainability in Dentistry program are available at 

fdiworlddental.org/sustainability-dentistry

Sustainably Manufacturing Dental Products

It might be a buzzword and often good for public relations, but that doesn’t mean corporate efforts to make operations more sustainable aren’t also good for business. Dental manufacturers have been making major efforts to reduce their use of resources and to decrease waste and harmful emissions. Here are some sustainability success statistics from around the dental industry.

There was a 15% reduction in both water withdrawal at warehouses and manufacturing plants and scope 1 and 2 greenhouse gas emissions.

There were 1,200,000 to 1,500,000 gallons of water per year saved by operational changes that focused on efficient use of resources.

There was a 74% mitigation of carbon impact from shipping parcels by next-day air through a partnership with United Parcel Service, making ground transportation possible.

There were 4.7 tons less of plastic used each year after changing product packaging from plastic to regular and carton paper materials.

A total of 72% of the energy used at company facilities in 2021 came from 100% renewable sources, including solar and hydroelectric power.

Almost 50% less polymer is used to make an aligner today compared with aligners made in 2016. Additionally, 33% less resin is used to make 3D-printed models for aligner production.

There were 1.2 million pounds less of carbon dioxide emissions released in 2023 when compared with 2022. This reduction is due to a new efficient air compressor system in a production facility.

Sustainability Report 2022. Dentsply Sirona. 2022. Accessed March 12, 2024. 

https://www.dentsplysirona.com/content/dam/master/corporate/merchandise/documents/CORP-document-2022-sustainability-report-EN.pdf

Social Responsibility and Sustainability Report 2024. Ultradent. 2024. Accessed March 12, 2024. 

https://assets.ctfassets.net/wfptrcrbtkd0/5jrCFrL1g5FBrOrDCjf4mM/ada05959d110e7895edb5cd1749899e9/UPI_SRS_Report_2024.pdf

2022 Sustainability and Corporate Social Responsibility Report. Henry Schein. 2022. Accessed March 12, 2024. 

https://www.henryschein.com/us-en/images/corporate/2022CSRReport.pdf

GC Group Global CSR Report 2023. GC Dental. 2023. Accessed March 13, 2024. 

https://www.gc.dental/america/sites/america.gc.dental/files/documents/2023-10/gc-csr-2023.pdf

Corporate Social Responsibility Review 2022. Ivoclar. 2022. Accessed March 13, 2024. 

https://www.ivoclar.com/GLOBAL%20-%20MEDIA/Corporate%20Content/Responsibility/CSR%20Report%202022_EN.pdf

Corporate social responsibility. Align Technology. Accessed March 13, 2024. 

https://www.aligntech.com/about/corporate_social_responsibility

2023 Corporate Responsibility Report. Midmark. 2023. Accessed March 13, 2024. 

https://www.midmark.com/docs/default-source/documents/2023-corporate-responsibility-report.pdf

Making a dental practice more sustainable can take many forms, and any effort that makes a positive impact is worthwhile. Here’s a look at some dental products that might be able to help with those efforts.

Curaprox Wooden Toothbrush

Trap-Eze Plaster Plus™

Bio Nitrile Powder Free Biodegradable Examination Gloves

EcoChoice Compostable Dental Flossers

BioGREEN™ Biodegradable Micro-Applicators

Sustainable Opportunities

How the dental industry is working to lighten its environmental impact.

Practicing Dentistry Sustainably

Carrying the mantle of a standard setter is not an easy task.

This is true for the child of a hall-of-famer and it’s just as true for the next generation of an iconic dental product. So when the research and development team at J MORITA MFG CORP set out to develop what is now the Root ZX3, they knew that to live up to the legacy of the name Root ZX, the goal must be to open a new paradigm in endodontic treatment.

With the introduction of a module capable of high-frequency conduction (HFC) therapy, and the same reliable apex location technology used in every Root ZX apex locator, the Root ZX3 is designed to be just that, says Kazunari Matoba, a former general manager of research and development at J MORITA MFG CORP who oversaw the development of the Root ZX line.

“Until now, the machines that have existed in root canal treatment have been those that help the act of treatment to make the diagnosis accurate and the treatment fast and easy,” Matoba says. “The HF Module is the first product to enter a new field where by its high-frequency conduction, symptoms are expected to improve due to the natural healing process of the human body…in cases where doctors are having trouble with treatment and healing is not possible. I am excited that we have entered a new world.”

Getting to that world was not a straight line, but neither was the development of the Root ZX technology that functions in any canal environment and provides accuracy that’s been measured at 97.5%.

 The accuracy is the key detail that makes the Root ZX apex locator so important, and Matoba says that when looking to create a solution for dentists, it was clear that precise, accurate measurement could make endodontic treatment easier and more predictable for everyone.

“It all started when I met doctors,” he says. “You can’t do proper development without knowing clinical practice. Endodontics is a field where the best solution for treatment is completely different from person to person. If you ask 5 doctors a question, sometimes all 5 will give you completely different answers. I was also troubled at that time. I wondered who was the most correct.”

Launched in 1991, the original Root ZX and its successors have been shown to be highly reliable systems for accurate measurement of the location of the apical constriction to determine the working length of the canal. Still, many endodontic treatments are performed today without an electronic apex locator, with clinicians using radiographs, tactile sensation, and other methods to determine the working length.

Early generations of apex locator technology did not provide the accuracy or reliability required for clinical use due to moisture in the canal or other issues.

 Using a technology called the ratio method that takes measurements of the ratio between the impedances of 2 electronic currents, the Root ZX solved many of the problems with earlier generations of electronic apex locator solutions and lived up to the promise of a technology dreamed up more than 70 years earlier.

Levitt Ellsworth Custer, DDS, was the first to describe using electric current to measure when an endodontic file reaches the apex of the root canal in a 1918 article in 

The Journal of the National Dental Association

. An early proponent of the use of electrical technologies in the practice of dentistry, Dr Custer did not see his apex location theories put to use in his lifetime.

 However, the concept was further tested in the 1940s and finally launched as a commercial product in 1969. Unfortunately, the first generation of apex locators used alternating current and resistance and were less accurate than radiographic measurement. A second wave of technologies based on single-frequency impedance measurements were also shown to be unreliable.

The Root ZX was among a third generation of apex locators, and as noted above, it offered the reliability necessary for clinical use. Since that time multiple new technologies for apex location and canal length measure have been developed, but the Root ZX remains a standard bearer for apex locator accuracy today, and technology that powers the original Root ZX is a key component of all of its successors.

“We don’t intend to say that we’re completely redesigning the model,” Matoba says. “The apex locator’s bar in the Root ZX3 has been greatly improved to shift smoothly. It is very easy to use. However, even as we have made these improvements, we have not changed from the original Root ZX all the way through.”

Over the years new versions of the Root ZX have found innovative ways to incorporate this foundational apex locator technology. In 1996 the Tri Auto ZX integrated apex location technology directly into an endodontic handpiece. Then in 2007, the Root ZX II added the possibility of integrating different modules into the device.

This was followed in 2009 by the Root ZX mini, which put the same apex location technology in a small and convenient form factor. In 2014 the OTR Module made it possible to connect a low speed handpiece directly to the Root ZX II. In 2017 the Tri Auto ZX2 upgraded the integrated endodontic handpiece–apex locator solution. Now the Root ZX3 is joining this legacy.

What the Root ZX3 and HFC Therapy Accomplish

While the core apex locator technology remains the same, the Root ZX3 packs everything into a smaller footprint with a larger display screen featuring 40 indicator bars providing real-time readings of the file location within the canal and an audio signal to provide warnings even when the clinician is not looking at the device.

Those upgrades improve the core function of the device, but the HF Module that attaches to the back of the Root ZX3 brings a new treatment approach to endodontics. HFC therapy can be used to cauterize and coagulate tissue, which can be used to create hemostasis during a pulpectomy. The therapy can also be applied during retreatment to cauterize infected tissue. The module can also be used for gingival procedures including gingivectomies, gingival polypectomies, and gingival retraction.

HF Therapy

The HFC therapy treatment can be performed using HF endo files or specialized electrode tips depending on the procedure, and multiple modes and output settings can be used to customize the treatment. The technology takes advantage of the apex locator to show where the file is in the canal, and the HFC is used to heat the tip of the file to cauterize or ablate tissue.

Matoba says the work he and his team produced with the Root ZX3 is a great accomplishment. He hopes HFC can help provide treatment to situations that were previously challenging to deal with. Still, he believes even more progress can be made in endodontic technologies.

“The most important thing is to prevent endodontic treatment,” he says. “I think it is our job to prevent endodontic treatment by utilizing the comprehensive capabilities of J MORITA MFG CORP. We are probably at the forefront of this kind of prevention, so our ideal vision for the future of the endodontic field is to create preventive machines that will prevent endodontic diseases from occurring.”

Guise GM, Goodell GG, Imamura GM. In vitro comparison of three electronic apex locators. 

. 2010;36(2):279-281. doi:10.1016/j.joen.2009.09.016

Gordon MP, Chandler, NP. Electronic apex locators. 

Gutmann JL. Origins of the electronic apex locator - achieving success with strict adherence to business. 

Built on the same reliable, accurate technology as the original Root ZX apex locator, the new Root ZX3 from J MORITA aims to be equally innovative with the integration of high-frequency conduction therapy.

Living Up to the Name of an Endodontic Technology Icon

Dental practices that provide excellent care and a good patient experience consistently have their chairs full and an easier time reaching profitability. Even if you are doing a good job on the services that you perform, a negative patient experience can lead to serious financial consequences for your dental practice. Improving billing practices is one way to give your practice a boost.

Effective communication is key to preventing any misunderstandings regarding billing with your patients. Your dental practice can take proactive steps to educate patients about your billing procedures, their insurance coverage, and the payment options that you accept. Ensure that your staff members are well-versed in explaining billing. Many patients are unsure of their dental coverage, and a little bit of communication and education can go a long way.

Simplify the billing process at your dental practice as much as possible. Implement streamlined systems that make it easy to bill promptly and submit insurance paperwork. Working with a partner, like APEX Reimbursement Specialists, can help you to ensure that you are using all the tools at your disposal. There are many types of software available today that can expedite the billing cycle, reduce errors, and make sure that the billing process is as easy for your dental practice and patients as possible.

Financial concerns can often deter patients from seeking essential dental care. Offering flexible payment options can help alleviate this concern and improve the patient experience at your dental practice. Consider offering installment plans through a third-party financing company so that your patients don’t feel like they need to delay the dental care that they need because of their finances.

Insurance claims and coverage complexities can be overwhelming for patients of your dental practice. Your practice can proactively assist patients in understanding their insurance benefits by confirming their benefits ahead of time and providing them with an accurate estimate of their treatment costs. Make sure that you are regularly confirming coverage with insurance companies, as patients often have benefits or plans change from year to year.

One of the best ways to improve the billing practices at your dental practice is by asking your patients for feedback. Encourage feedback from patients regarding their billing experiences. Constructive criticism can unveil areas for improvement that you aren’t currently aware of. Implement a system to gather patient feedback, be it through surveys, direct conversations, or online reviews. The most valuable feedback comes directly from the patients you work with every day.

Improve Your Dental Practice with Experienced Specialists

Your dental practice can prioritize the patient experience in a variety of ways, including improving your billing. 

Dental Products Report April 2024